Analysis The victim fell overboard into the water while attempting to perform a gymnastic manoeuvre on the forward railing. His ability to stay afloat unaided, or swim to shore, would have been affected by hypothermia due to the low water temperature. The MissGatineau was not suitably equipped to conduct an effective SAR operation in the dark and was not equipped with a suitable motorized lifeboat. No specific lookout was assigned to keep track of the victim in the water, which resulted in the crew losing sight of him. A lack of understanding of the impact of river currents on a person in the water resulted in neither the crew nor the water rescue units proceeding immediately downstream to search for the victim.Findings as to Causes and Contributing Factors The victim fell overboard into the water while attempting to perform a gymnastic manoeuvre on the forward railing. His ability to stay afloat unaided, or swim to shore, would have been affected by hypothermia due to the low water temperature. The MissGatineau was not suitably equipped to conduct an effective SAR operation in the dark and was not equipped with a suitable motorized lifeboat. No specific lookout was assigned to keep track of the victim in the water, which resulted in the crew losing sight of him. A lack of understanding of the impact of river currents on a person in the water resulted in neither the crew nor the water rescue units proceeding immediately downstream to search for the victim. There is no marine VHF radio coverage for vessels operating on the Ottawa River between Carillon and Ottawa that provides access to the SAR system; this reduces the probability of an effective coordinated SAR response in the event of a distress situation. A lack of joint training exercises among various municipally and federally supported SAR resources increases the likelihood that a distress or other emergency situation on the waterways of the Ottawa and Gatineau rivers will not receive a coordinated response.Findings as to Risk There is no marine VHF radio coverage for vessels operating on the Ottawa River between Carillon and Ottawa that provides access to the SAR system; this reduces the probability of an effective coordinated SAR response in the event of a distress situation. A lack of joint training exercises among various municipally and federally supported SAR resources increases the likelihood that a distress or other emergency situation on the waterways of the Ottawa and Gatineau rivers will not receive a coordinated response. Safety Action Action Taken TCMS A TSB Marine Safety Advisory (MSA 10/00) was sent to TCMS describing the importance of having means available to quickly locate and recover passengers or crew members who fall overboard. The MSA suggested TCMS consider measures to ensure that excursion boats (such as the MissGatineau and other similar passenger vessels) have adequate equipment on board, and have the capability to locate and recover expediently persons who fall overboard, under all of the environmental conditions the vessel might encounter in normal service. In its response, TCMS indicated that amendments to the Ship Station (Radio) Regulations, 1999, will require all passenger vessels to have reliable means of communicating with the shore. Additionally, TCMS will be carrying out an overall review of standards and requirements for lifesaving equipment, including lifeboat requirements; there is a possibility of requiring searchlights on passenger vessels similar to the MissGatineau. Vessel Owner Subsequent to the occurrence, the owner installed screens on all opening windows to prevent passengers or crew from falling or jumping overboard. Ottawa Fire Department The OFD water rescue unit subsequently equipped its rescue vessels with marine VHF radios. Safety Concern While CCG SAR has overall responsibility for administering the national marine SAR program, the National SAR Manual does not include the Ottawa River as an area within the responsibility of CCG SAR. Notwithstanding this, the Board is aware that the CCG does maintain a presence in the area in the form of three CCG Auxiliary craft, and has participated in a joint coordination meeting of local municipal marine SAR resources. At the time of the occurrence, local municipal marine rescue services responded quickly; however, subsequent SAR activities were not well coordinated. Marine rescue units from local municipal fire departments did not have a common means of communication (either with each other or with the MissGatineau) nor were they aware of one another's capabilities or of the availability of CCG Auxiliary craft in the area. With a growing number of commercial passenger vessels in the Ottawa/Hull area, it is essential that effective marine SAR resources be available to respond to emergencies. One of the CCG SAR program objectives is to foster co-operative SAR agreements. At the May 1999 meeting of local emergency response agencies, some progress was made towards enhancing marine radio communications and SAR awareness in the Ottawa/Hull area; however, the Board is concerned that channel 16 VHF radio communications in the Ottawa area still cannot be monitored by MCTS stations, and that local communications and SAR resources are not effectively organized or coordinated by CCG SAR.